Michigan — Targeted Issue

Michigan Pediatric Errors and Excellence Discovery with Simulation (MI-PE2DS)

Sept. 1, 2008 - Aug. 31, 2012

Based at:: Michigan State University, Kalamazoo Center for Medical Studies

Contacts

Name	Role(s)	Phone	Email
Richard Lammers, MD	Principal Investigator

If you are interested in connecting with Family Advisory Network (FAN) representatives, please contact the Program Manager to obtain their email or phone number.

Disseminations

Title	Type	Publication/Event	Published/Presented	Identifier	Details
Errors and Error-Producing Conditions During a Simulated, Prehospital Pediatric Cardiopulmonary Arrest	Research Paper/Publication	Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare	2014	PMID: 24401924	Errors and Error-Producing Conditions During a Simulated, Prehospital Pediatric Cardiopulmonary Arrest Author(s)/Presenter(s) Lammers, Richard L. MD; Willoughby-Byrwa, Maria BS, EMT-P, I/C; Fales, William D. MD Abstract/Description Introduction: Management of pediatric cardiac arrest challenges the skills of prehospital care providers. Errors and error-producing conditions are difficult to identify from retrospective records. The objective of this study was to identify errors committed by prehospital care providers and the underlying causes of those errors during a simulated pediatric cardiopulmonary arrest followed by a structured debriefing. Methods: Performance criteria were defined prospectively by an advisory panel. Prehospital care providers from 6 emergency medical service agencies in Michigan participated in a simulation of an infant cardiopulmonary arrest using their own drugs, equipment, and protocols in a mobile trailer. Simulations were video-recorded and played back during debriefings that were conducted immediately after the event to facilitate error analysis. Observed errors and subjects’ explanations were analyzed by thematic qualitative assessment methods and descriptive statistics. Results: One hundred ninety-four subjects, including paramedics, emergency medical technicians, and emergency medical responders in various crew configurations, participated in 60 simulation sessions during a 5-month period (April to August of 2010). Error types were classified into 4 clinically important themes as follows: failure to provide adequate ventilation, failure to provide effective circulation, failure to achieve vascular access rapidly, and medication errors. Multiple underlying causes of medication dosing and other errors were identified, including cognitive, procedural, communication, teamwork, and systems factors. Conclusions: We systematically observed many types of errors and identified some of the underlying causes during a simulated, prehospital, pediatric cardiopulmonary arrest. There were numerous, multifactorial, and sometimes, synergistic causes of medication dosing errors. Emergency medical service officials can use these findings to prevent future errors. View On Pub Med
Medication Errors in Prehospital Management of Simulated Pediatric Anaphylaxis	Research Paper/Publication	Prehospital Emergency Care	2014	PMID: 24401046	Medication Errors in Prehospital Management of Simulated Pediatric Anaphylaxis Author(s)/Presenter(s) Richard Lammers, Maria Willoughby-Byrwa, William Fales Abstract/Description Background: Systematic evaluation of the performances of prehospital providers during actual pediatric anaphylaxis cases has never been reported. Epinephrine medication errors in pediatric resuscitation are common, but the root causes of these errors are not fully understood. Objective: The primary objective of this study was to identify underlying causes of prehospital medication errors that were observed during a simulated pediatric anaphylaxis reaction. Methods: Two- and 4-person emergency medical services crews from eight geographically diverse agencies participated in a 20-minute simulation of a 5-year old child with progressive respiratory distress and hypotension from an anaphylactic reaction. Crews used their own equipment and drugs. A checklist-based scoring protocol was developed to help identify errors. A trained facilitator conducted a structured debriefing, supplemented by playback of video recordings, immediately after the simulated event to elicit underlying causes of errors. Errors were analyzed with mixed quantitative and qualitative methods. Results: One hundred forty-two subjects participated in 62 simulation sessions. Ninety-five percent of crews (59/62) gave epinephrine, but 27 of those crews (46%) delivered the correct dose of epinephrine in an appropriate concentration and route. Twelve crews (20%) gave a dose that was ≥5 times the correct dose; 8 crews (14%) bolused epinephrine intravenously. Among the 55 crews who gave diphenhydramine, 4 delivered the protocol-based dose. Three crews provided an intravenous steroid, and 1 used the protocol-based dose. Underlying causes of errors were categorized into eight themes: faulty reasoning, weight estimation errors, faulty recall of medication dosages, problematic references, calculation errors, dose estimation, communication errors, and medication delivery errors. Conclusion: Simulation, followed by a structured debriefing, identified multiple, underlying causes of medication errors in the prehospital management of pediatric anaphylactic reactions. Sequential and synergistic errors were observed with epinephrine delivery. View On Pub Med
Root Causes of Errors in a Simulated Prehospital Pediatric Emergency	Research Paper/Publication	Academic Emergency Medicine	2012	PMID: 22251191	Root Causes of Errors in a Simulated Prehospital Pediatric Emergency Author(s)/Presenter(s) Richard Lammers, Maria Byrwa, William Fales Abstract/Description Objectives: Systematic evaluation of prehospital provider performance during actual resuscitations is difficult. Although prior studies reported pediatric drug-dosing mistakes and other types of management errors, the underlying causes of those errors were not investigated. The objective of this study was to identify causes of errors during a simulated, prehospital pediatric emergency. Methods: Two-person emergency medical services (EMS) crews from five geographically diverse agencies participated in a validated simulation of an infant with altered mental status, seizures, and respiratory arrest using their own equipment and drugs. A scoring protocol was used to identify errors. A debriefing conducted by a trained facilitator immediately after the simulated event elicited root causes of active and latent errors, which were analyzed by thematic qualitative assessment methods. Results: Forty-five crews completed the study. Clinically important themes that emerged from the data included oxygen delivery, equipment organization and use, glucose measurement, drug administration, and inappropriate cardiopulmonary resuscitation. Delay in delivery of supplemental oxygen resulted from two different automaticity errors and a 54% failure rate in using an oropharyngeal airway (OPA). Most crews struggled to locate essential pediatric equipment. Three found broken or inoperable bag/valve/masks (BVMs), resulting in delayed ventilation. Some mistrusted their intraosseous (IO) injection gun device; others used it incorrectly. Only 51% of crews measured blood glucose; some discovered that glucometers were not stored in their sealed pediatric bags. The error rate for diazepam dosing was 47%; for midazolam, it was 60%. Underlying causes of dosing errors were found in four domains (cognitive, procedural, affective, and teamwork), and they included incorrect estimates of weight, incorrect use of the Broselow pediatric emergency tape, faulty recollection of doses, difficulty with calculations under stress, mg/kg to mg to mL conversion errors, inaccurate measurement of volumes, use of the wrong end of prefilled syringes, and failure to crosscheck doses with partners. Conclusions: Simulation, followed immediately by facilitated debriefing, uncovered underlying causes of active cognitive, procedural, affective, and teamwork errors, latent errors, and error-producing conditions in EMS pediatric care. View On Pub Med
Simulation-based assessment of paramedic pediatric resuscitation skills	Research Paper/Publication	Prehospital Emergency Care	2009	PMID: 19499472	Simulation-based assessment of paramedic pediatric resuscitation skills Author(s)/Presenter(s) Lammers RL, Byrwa MJ, Fales WD, Hale RA Abstract/Description Background: Emergency medical services (EMS) providers infrequently encounter seriously ill and injured pediatric patients. Clinical simulations are useful for assessing skill level, especially for low-frequency, high-risk problems. Objective: To identify the most common performance deficiencies in paramedics' management of three simulated pediatric emergencies. Methods: Paramedics from five EMS agencies in Michigan were eligible subjects for this prospective, observational study. Three clinical assessment modules (CAMs) were designed and validated using pediatric simulators with varying technologic complexity. Scenarios included an infant cardiopulmonary arrest, sepsis/seizure, and child asthma/respiratory arrest. Each scenario required paramedics to perform an assessment and provide appropriate pediatric patient care within a 12-minute time limit. Trained instructors conducted the simulations by following strict guidelines for sequences of events and responses. Videos of CAMs were reviewed by an independent evaluator to verify scoring accuracy. Percentage of steps completed for each of the three scenarios and specific performance deficiencies were recorded. Results: Two hundred twelve paramedics completed the CAMs. The average percentages of steps completed were as follows: arrest CAM, 45.3%; asthma CAM, 51.6%; and sepsis CAM, 47.1%. Performance deficiencies included lack of airway support or protection; lack of support of ventilations or cardiac function; inappropriate use of length-based treatment tapes; and inaccurate calculation and administration of medications and fluids. Conclusion: Multiple deficiencies in paramedics' performance of pediatric resuscitation skills were objectively identified using three manikin-based simulations. EMS educators and EMS medical directors should target these specific skill deficiencies when developing continuing education in prehospital pediatric patient care. View On Pub Med

Overview

EMS personnel infrequently encounter critically ill or injured children. Clinical skills that are used infrequently will deteriorate. Recent studies of paramedics have demonstrated unacceptably high rates of errors in both prehospital care of children and in simulations of pediatric emergencies. Little is known about the underlying causes of technical, cognitive, or team-based pediatric EMS errors, or about combinations of factors that result in optimal treatment. Simulation provides a method of studying quality of care in rare clinical events. The goals of this project are to (1) develop and conduct a series of comprehensive, realistic pediatric clinical simulations for use by EMS personnel in a model mobile simulation laboratory for the purpose of discovering performance errors and identifying exemplary individual and team performance using root cause analysis methodology; and 2) compare errors detected in simulations with errors identified in similar case controls using a statewide electronic EMS information system.

Main Contact

Richard Lammers, MD

Award Amount

$750,000